HomeMy WebLinkAbout0852A � WORKERS'COMPENSATIONDECLARATION 76A663 +0�8+ APPLICATION FOR ELECTRICAL PERMIT {�
I hereby aflirm that I have u certiticate of consent to self insure, CE-806G
or a certif'�ate of Nbrkers'Compensation Insurance,or a certilied COUNTY OF LOS ANGELES BUILDING AND SAFETY u
coDY the�eof(Sec.3800.Lab.C.)
PoIICy N0. ��� � � , �mparnj FOR APPLICAM TO FlLL IN J�9 �"
❑ Certified copy S hcreby turnished. New Resitlential Bldgs.8 Pools EACH NO. FEE �DaESS �� N. �-c�'�'��IJOO�
� Certified copy is filed with the county buildirg inspeCtion 1&2•Family,Sq.Ft. � — S LOCAIJTY ���.rypN]� Q'}2
department. � - � . Multi-famiiy Sq.Ft. � — NeaREsr
CROSS ST. SYLlJA1V C7LF.N
Date ADP��cant� � � � ReSidential Swimming Pools y _ pwNER oR T�1 .--�`e�'���-
`��y'�'�''� FlRM NAME ayf��� 6• �G�"'�Tw��
CERTiFICCOM ENSATION NS R�CEORKERS' p��e�s:Rec_�Lght_Sw.— K o DDRESS � N• �E�R��.V Q
, (This seclbn need not 6e completeU R the work invdved by the Frst 20
permit Is lor one hu�dred dollars($100)or 1e68J
Total No. Adaitionat CITY �j�0 u'D �R(t Tei.No.7�t�86o�.q$3
I certiy[hat in ihe performance of the work for which this permit PLAN CHECK
is issued,I shall not empioy arry person in arry manner so as�0 � APPL�CAM f� �7 •��QST
bemme wbject to the Workers'Compensati . L'ghting Fixtwes First 20 ADDRESS � �
� � �,B 7 . r '. Total No. Additional
ate Applica '1 CITY Tel.No.
NOTICE TO APPLICANT: If, after making this Certificate of Fxed Appliances Not Over 1 HP F£fiMlT W+�,..�
�Exemptbn,y�w stwuld become subject to tFre 4Wrkers'Compensation Range_Heater_ DW. _ AP7�-�C1`riT � ��VE N��
provisions of the la6or Code,you must forlMvith comply with suCh Oven_Dryer_ W M._ ADDRE55
�provisions or this permit shall be deemed rewked. Top. —FAU _ W.H._ .
� LICENSED CONTRAC70R5 OECLARATION - qTY Tel.No.
Hood— Fan _ Other_
1 hereby alfirm that I am ficensed under provisions oF Chapter 9 DiSp. —ROOm Aif Cqnd. _ L�CENSE OR aazx
(commencing with SeMion 7D00)ot DNisbn 3 oF the Business and REG.NUM9ER
Prolessions Code,and my license is in fult torce and eftect. o�STRiCr rvo. raoCesseo ev
� Power Apparetus 8 Laige Apdiances . . _
Size 8 Type HP,KW,KVA,or KVAR /J O
License Number Lic.Ctass � � Up to 1 Incl.-� � � FINAL�/�`�^ U
Contractor �- Date � � �1 to 70 Incl. . �A� U VALIDATION _ O
❑ Over 10 to 50 Incl. �A, � F.-,
I am exempt urWer Sec. Over 50 to 700 Inc. ��'
a�1��% W
B.SP.C.tor this reason Over 700 �
. . . _ � Servkes,Sw6d,MCC&Parelboards� , � - - - Z
Date: 0-200 Amp.Under 600 V
Signature � 201-7000 Amp.Under 600 V - � � �
❑ Over 1000 Amp.a Over 600 V
Eaemption tor Reg.Maint.Elect.
SINGLE FAMILY- Temp.Power Pe!e 8 Appurt=nerxes �O S S Z A
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit � ♦ i • • •2
�hereby affirm that I am exempt from the Contractors LicenSe LaW ,
fOf�I10�OIIOWI00 fQ9500(SGCIi00�O3LS,BUSIM55 BIIA RT1fP.55iO�S Additbnal Sgn&anch Circuits - � = =v Q v�
Code):
Misa Conduits 8 Conductors � • • •3 0.5 0 c=a
I,as owner ol the property,will do the work and the strucfure Other(See Comptete Fce Schedule)_
is rrot inteMed or offered for sale(Seclion 7044,Business , Q Q� 8•-$7
and Professions Code). �
CONSTRUCTION LENDING AGENCY
I hereby alfirm that there is a constmction lending agency for the
performance of the work for which this permit is issued(Sec.3097, pERMfT FEE (Sub-Total) �j W � �
Civ.C.).
. PLAN CHECKING FEE � -
Lender's Name
� ' PERMR ISSUING FEE �G .
Lender's Address r� �r
I certiy that I ha�,e read this application and state that the abova TOTAL FEE . . cJ�l.U� . _. .
Information is carec[.I agree to tomply with ali County ordinances
and S[ate laws regulatirg Electrical wirirg,and hereby authorize ._ . _ .
representatives ot this County to enter upon Ihe above-men[ioned
erty for in,�pec[ipn purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
� 81787
i�nature of Permittee Date
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